Differences in Characteristics and Downstream Drug Use Among Opioid-Naïve and Prior Opioid Users with Low Back Pain

The mediating role of posttraumatic stress disorder symptoms in pain cognitions among Veterans with chronic pain

Symptoms of posttraumatic stress disorder (PTSD) are highly prevalent among Veterans with chronic pain. Considerable research has examined the intersection of chronic pain and PTSD symptoms. However, it remains unclear whether changes in PTSD may potentially serve a mechanistic role in improving unhelpful pain cognitions for individuals with chronic pain. The present research contributes to the foundational knowledge by addressing this question. Baseline data from a randomized controlled trial targeting pain-related disability for Veterans (n = 103; mean age 43.66; SD = 10.17) with musculoskeletal pain and depression and/or PTSD symptoms were used. Cross-sectional mediation analyses showed that PTSD symptoms mediated the relationship between pain severity and pain catastrophizing, and between pain severity and pain acceptance. After controlling for depression, the mediation involving pain catastrophizing remained significant, while the mediation for pain acceptance did not. Although limitations exist, results point to several treatment recommendations, including ensuring that depressive affect, PTSD-specific symptoms, and attention to both body and mind are included in treatment. Results also provide preliminary evidence for examining these associations longitudinally to improve our understanding of this population and corresponding treatment recommendations.

Identifying Patients Vulnerable to Inadequate Pain Resolution After Cardiac Surgery

Acute postoperative pain (APOP) is often evaluated through granular parameters, though monitoring postoperative pain using trends may better describe pain state. We investigated acute postoperative pain trajectories in cardiac surgical patients to identify subpopulations of pain resolution and elucidate predictors of problematic pain courses. We examined retrospective data from 2810 cardiac surgical patients at a single center. The k-means algorithm for longitudinal data was used to generate clusters of pain trajectories over the first 5 postoperative days. Patient characteristics were examined for association with cluster membership using ordinal and multinomial logistic regression. We identified 3 subgroups of pain resolution after cardiac surgery: 37.7% with good resolution, 44.2% with moderate resolution, and 18.2% exhibiting poor resolution. Type I diabetes (2.04 [1.00-4.16], p = 0.05), preoperative opioid use (1.65 [1.23-2.22], p = 0.001), and illicit drug use (1.89 [1.26-2.83], p = 0.002) elevated risk of membership into worse pain trajectory clusters. Female gender (1.72 [1.30-2.27], p < 0.001), depression (1.60 [1.03-2.50], p = 0.04) and chronic pain (3.28 [1.79-5.99], p < 0.001) increased risk of membership in the worst pain resolution cluster. This study defined 3 APOP resolution subgroups based on pain score trend after cardiac surgery and identified factors that predisposed patients to worse resolution. Patients with moderate or poor pain trajectory consumed more opioids and received them for longer before discharge. Future studies are warranted to determine if altering postoperative pain monitoring and management improve postoperative course of patients at risk of moderate or poor pain resolution.

Associates of Insomnia in People with Chronic Spinal Pain: A Systematic Review and Meta-Analysis

Insomnia is a major problem in the chronic spinal pain (CSP) population and has a negative impact on health and well-being. While insomnia is commonly reported, underlying mechanisms explaining the relation between sleep and pain are still not fully understood. Additionally, no reviews regarding the prevention of insomnia and/or associated factors in people with CSP are currently available. To gain a better understanding of the occurrence of insomnia and associated factors in this population, we conducted a systematic review of the literature exploring associates for insomnia in people with CSP in PubMed, Web of Science and Embase. Three independent reviewers extracted the data and performed the quality assessment. A meta-analysis was conducted for every potential associate presented in at least two studies. A total of 13 studies were found eligible, which together identified 25 different potential associates of insomnia in 24,817 people with CSP. Twelve studies had a cross-sectional design. Moderate-quality evidence showed a significantly higher rate for insomnia when one of the following factors was present: high pain intensity, anxiety and depression. Low-quality evidence showed increased odds for insomnia when one of the following factors was present: female sex, performing no professional activities and physical/musculoskeletal comorbidities. Higher healthcare use was also significantly related to the presence of insomnia. One study showed a strong association between high levels of pain catastrophizing and insomnia in people with chronic neck pain. Last, reduced odds for insomnia were found in physically active people with chronic low back pain compared to inactive people with chronic low back pain. This review provides an overview of the available literature regarding potential associates of insomnia in people with CSP. Several significant associates of insomnia were identified. These findings can be helpful to gain a better understanding of the characteristics and potential origin of insomnia in people witch CSP, to identify people with CSP who are (less) likely to have insomnia and to determine directions of future research in this area.

The Risk of Prior Opioid Exposure on Future Opioid Use and Comorbidities in Individuals With Non-Acute Musculoskeletal Knee Pain

Objectives

Due to their potentially deleterious effects, minimizing the use of opioids for musculoskeletal pain is a priority for healthcare systems. The objective of this study was to examine the risk of future opioid prescription use based on prior opioid use within a non-surgical cohort with musculoskeletal knee pain. We also examined the risk of pre-existing comorbidities on future opioid use, and the risk of prior opioid use on future comorbidities (sleep, mental health, cardiometabolic disorders).

Methods

Data came from the Military Health System Data Repository for 80 290 consecutive beneficiaries with an initial episode of care for patellofemoral pain from January 1, 2010 through December 31, 2011. Risk was calculated using 2 × 2 tables based on pre- and post-opioid utilization and comorbid diagnosis. Risk ratios, relative and absolute risk increases, and numbers needed to harm were calculated, all with 95% confidence intervals.

Results

Prior opioid use resulted in a risk ratio of 18.0 (95 CI 17.1, 19.0) and an absolute risk increase of 61.6% for future opioid use (numbers needed to harm = 2). The presence of all comorbidities (except cardiometabolic syndrome) were associated with a significant relative risk for future opioid use (RR range 1.2-1.5), but the absolute risk increase was trivial (range 0.7%-2.2%). The relative risk for a chronic pain diagnosis, traumatic brain injury/concussion, insomnia, depression, and PTSD were all significantly higher in those with prior opioid use (1.3-1.6), but absolute risk increase was minimal (1.1%-6.5%).

Discussion

Prior opioid use was a strong risk factor for future opioid use in non-surgical patients with knee pain. These findings show that history of prior opioid use is important when assessing the risk of future opioid use, whereas prior comorbidities may not be as important. Opioid history assessment should be standard practice for all patients with patellofemoral pain in whom an opioid prescription is considered.

The influence of prior opioid use on healthcare utilization and recurrence rates for non-surgical patients seeking initial care for patellofemoral pain

INTRODUCTION/OBJECTIVES

Prior opioid use can influence outcomes for patients with musculoskeletal disorders. The purpose of this study was to compare downstream medical utilization-based outcomes (costs, visits, recurrent episodes) after an initial diagnosis of patellofemoral pain based on pre-injury utilization of opioids.

METHOD

A total of 85,7880 consecutive patients were followed for a full 12 months before and 24 months after an initial diagnosis of patellofemoral pain (January 2009 to December 2013). Data were sourced from the Military Health System Data Repository, a single-payer closed government system. Opioid prescription fills were identified, and medical visits and costs were calculated for all knee-related medical care, to include recurrence rates in the 2-year surveillance period.

RESULTS

A relatively small number of individuals filled an opioid prescription in the year prior (n = 1746; 2.0%); however, these individuals had almost twice the mean costs of knee-related medical care ($1557 versus %802) and medical visits (8.4 versus 4.0). Patients with prior opioid use were more likely to have at least 1 recurrent episode of knee pain (relative risk 1.58, 95% CI 1.51, 1.65) with a higher mean number of episodes of knee pain (1.5 vs 1.8). The use of opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes of knee pain compared to the use of opioids in a lower risk category (Schedule IV).

CONCLUSIONS

Prior opioid utilization was associated with a greater number of recurrent episodes of knee pain and higher downstream medical costs compared with individuals without prior opioid use. For individuals with prior opioid utilization, opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes compared to the use of lower-risk opioids (Schedule IV). Key Points • Patients with prior opioid use had much greater knee-related medical costs compared to patients without prior opioid use. • Patients with prior opioid use were more likely to have additional episodes of knee pain in the following 2 years compared to patients without prior opioid use. • Prior opioid use has predicted higher costs and poor outcomes after surgery, but this is the first study to confirm similar findings in non-surgical patients.